Forms
Certificate of Exemption from Immunization (English)
Immunization - Form
August 31, 2023
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
Certificate of Exemption from Immunization (Spanish)
Immunization - Form
August 31, 2023
This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.
VFC Provider Staff Change of Contact and uploading Training
Immunization - Form
April 13, 2023
VFC Provider Staff Change of Contact and uploading Training
VFC Physician Signing Agreement Change of Contact
Immunization - Form
April 13, 2023
VFC Physician Signing Agreement Change of Contact
VFC Emergency Vaccine Management Plan
Immunization - Form
April 13, 2023
The New Mexico VFC Program requires each practice to develop and maintain an Emergency Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement to have a written plan for storage and handling procedures in an emergency.
VFC New Provider Application
Immunization - Form
April 13, 2023
All VFC providers are required to submit this annual VFC certification form in order to continue receiving VFC vaccines.
VFC Provider NM Health Passport Order Form
Immunization - Form
April 13, 2023
This form allows providers to order VFC supplies.
NMSIIS Organization Security and Confidentiality Agreement 2023
Immunization - Form
January 3, 2023
Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.
NMSIIS User Security and Confidentiality Agreement 2023
Immunization - Form
January 3, 2023
NMSIIS User Security and Confidentiality Agreement 2023
COVID-19 Vaccine Troubleshooting Report
Immunization - Form
August 24, 2022
COVID-19 Vaccine Troubleshooting Report
VFC School Immunization Consent Form
Immunization - Form
August 17, 2022
This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.
VFC Vaccine Administration Form (Part B)
Immunization - Form
August 17, 2022
This form allows you to provide immunization information for entry into NMSIIS.
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
Immunization - Form
May 18, 2022
CDC-Revised document as COVID-19 Vaccine Program Provider Agreement
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
Immunization - Form
May 18, 2022
CDC-Supplemental document as COVID-19 Vaccine Redistribution Agreement
NMSIIS Decision to Remove Record
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.
NMSIIS Decline to Participate Form
Immunization - Form
December 30, 2021
This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.
Adult Vaccine Consent Form
Immunization - Form
October 1, 2021
This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.
Got Shots Fillable Form
Immunization - Form
July 1, 2021
Got Shots Fillable Form
Got Shots? Fillable Form - Eng
Got Shots? Fillable Form - Esp